All Entries Tagged With: "documentation"

Add analysis of severity adjusted data to your CDI activities

Catapult your CDI program with SOI/ROM assessments.

The days of capturing a patient’s condition solely through complications and comorbidities (CC) and major CCs (MCC) are slowly fading. There is a new focus on capturing severity of illness (SOI) and risk of mortality (ROM), and clinical documentation improvement (CDI) programs are taking notice.

And why shouldn’t they? SOI and ROM programs provide a higher level of detail about a patient’s condition and the care provided. They also strengthen hospitals’ quality data and physician report cards, which in turn improve revenue and reduce compliance risk.

During a September 18 HCPro audio conference, “Severity of Illness and Risk of Mortality: Sharpen Your CDI Focus with New Measures of Success,” speaker Garri L. Garrison, RN, CPC, CMC, CPUR, defined SOI as “the extent of physiological decomposition or organ system loss of function experienced by the patient.” Or in simpler terms, “how sick is the patient?” In self-explanatory terms, ROM is meant to indicate the patient’s likelihood of dying.

These two terms should catapult your CDI program to new heights of clinical specificity. A severity adjusted program is an ideal method to carry out your new and improved CDI efforts. A severity adjustment program allows hospitals, consumers, payers, and regulators to understand the patients being treated, the costs incurred and, within reasonable limits, the services and outcomes expected.

October 28, 2009 | Melissa Varnavas | Comments 1

Talk about documentation catches, simple mistakes cause profound costs

Sometimes documentation mistakes caught by CDI professionals are the simple ones. Like an incorrect date. I recently came upon this news brief from New York Injury News which outlined the trials of HIV patient who lost his coverage due to inaccurate documentation of a blood-test date.

You find vital information in the medical record everyday. Tell us about some of your 'best find' stories.

As compassionate people living day-to-day it’s easy to vilify the insurance company for dropping a sick person from its coverage rosters, or point the finger at the patient for not keeping better tabs on his or her clinical and coverage information. Yet CDI professionals well know the costs of seemingly simple mistakes. This particular case ended up costing the insurance company, Fortis, $10 million for inappropriate denial of healthcare coverage and added untold difficulties to a young man’s life.

Well, I know that CDI specialists catch these seemingly simple mistakes all the time. So here’s a special request to ACDIS Blog readers—wouldn’t it be nice to receive recognition for those otherwise unseen documentation catches you make everyday? Send me your funniest, most heart wrenching, or simply ‘best catch’ documentation stories by the end of October. We’ll run them by our editorial panel and pick the best to publish. E-mail me at mvarnavas@cdiassociation.com.

October 13, 2009 | Melissa Varnavas | Comments 2

Much ado about the flu vaccine

You probably know all the pros and cons of getting the yearly flu vaccination far better than me. I’ve been inundated with propaganda from both sides of the argument—to get the flu shot or not (yes, I’m struggling to avoid another Shakespeare reference). In fact, just this morning someone sent me a clip from a Fox News video of a physician stating the vaccine for H1N1 is deadlier than the disease. It listed nine reasons not to get vaccinated.

In the interest of self-disclosure I have not (to my knowledge) ever received the flu shot. It is offered here as a benefit of my employment. They even offer them on-site. But I never get one. I’m not

Alien tripod illustration by Alvim Corréa, from the 1906 French edition of H.G. Wells' "War of the Worlds".

sure why. I guess I believe in the wives tales—that the shot makes some people sick. And, besides if H.G. Well’s virus helped humans defeat an alien race, I could withstand a little sniffle in favor of the greater good of planet Earth. (Yes, I am that strong.)

In the fall of 2009, however, we’re not just talking about the annual incarnation of the seasonal flu that receives its share of the—vaccinate, don’t vaccinate—hype. This year receiving an inoculation for the seasonal flu and the potential pandemic of H1N1 “swine flu” seems more important than ever.

Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) urges healthcare facilities to require staff vaccinations for flu. The group made its recommendation August 31 as predictions from a presidential panel suggested that half of all Americans may be infected with the H1N1 virus during the upcoming flu season.

Just this week Indiana and Tennessee became the first to offer the H1N1 shots. At the end of September the swine flu swept through Austin, TX.

Rates of healthcare provider vaccinations for the simple seasonal shot, however, hover at the 42% mark, a rate that has not budged much in the last decade, according to the APIC. The Centers for Disease Control and Prevention, as well as APIC, recommend that all healthcare workers in direct contact with patients get a flu vaccination to keep patients safe.

My husband, a special education teacher here in Massachusetts, gets his vaccinations every year religiously. My elderly relatives to do too. For some reason I’m still not sold.

Let me know you feel about this season’s various flu threats. Tell me about any flu-type challenges you see specific to CDI specialists regarding complications, documentation, and/or simple staffing considerations. If you have already had to deal with an H1N1 case, I’d love to hear from you.

Most of all, stay healthy.

To read more about required flu vaccination for healthcare workers, go to HealthLeadersMedia.com. (There’s an interesting Blog post from my friend and co-worker Gienna Shaw that shows how one hospital engaged its staff in a video about the importance of the H1N1 flu shot. It’s really cute. Definitely worth a watch.)

Don’t forget to read the CDC’s “flu facts,” too. They may seem like simple common knowledge but they’re always worth a quick review.

Oh, and I just got this in my e-mail inbox from CMS!

Flu Season is upon us! CMS encourages providers to begin taking advantage of each office visit to encourage your patients with Medicare to get seasonal flu shots. Flu shots are their best defense against combating flu this season. And don’t forget—health care workers also need to protect themselves.

Medicare provides coverage of the flu vaccine without any out-of-pocket costs to the Medicare patient as a part B benefit. No deductible or copayment/coinsurance applies. Note that influenza vaccine is NOT a Part D covered Drug.

For more information about Medicare’s coverage of the seasonal influenza vaccine and its administration, as well as related educational resources for health care professionals, please go to the CMS Web site. For information on Medicare policies related to H1N1 influenza, please go to www.cms.hhs.gov/H1N1 on the CMS Web site.

October 08, 2009 | Melissa Varnavas | Comments 9

Physician buy in for E/M services

From the Documentation Guideline for E/M Services (Centers for Medicare and Medicaid Services):

To determine the appropriate level of service for a patient’s visit, it is necessary to first determine whether the patient is new or established. The Physician must then uses the presenting illness as a guiding factor to determine the extent of key elements of service to be performed. The key elements are:

History
Examination
Medical decision making

History: The physician must determine the type of history. Is it Problem focused, Expanded focus, Detailed, or Comprehensive.

Exam: The examination may involve several organ systems or a single organ system. The extent of the exam performed is based upon clinical judgment, patient history and the nature of the presenting problem. The type of exam must be determined to be:

Problem focused
Expanded focus
Detailed
Comprehensive

Medical Decision Making: Medical Decision making refers to the complexity of establishing a diagnosis and/or selecting a management option. A number of options must be considered.

The number of possible diagnosis and or management options
The amount and /or complexity of medical records, diagnostic tests and /or other information that must be reviewed and analyzed.
-The risk of significant complications, morbidity, and/or mortality as well as co morbidities associated with the patient’s presenting problem, the diagnostic procedures and /or the management options.

The level of decision making must be determined to be:

Straightforward
Low Complexity
Moderate Complexity
High Complexity

Some important points that should be kept in mind when documenting level of risk are:

Comorbidities/Underlying disease
Surgical or invasive diagnostic procedures ordered, planned or scheduled.
Surgical or invasive diagnostic procedure performed.
The referral for or decision to perform a surgical or invasive diagnostic procedure.

When counseling and/or coordination of care dominates the patient encounter (more than 50%), time is considered the key or controlling factor for a particular E/M service. Presenting problems that affect level of risk include:

Minimal: Minor problems such as colds, insect bites, etc.
Low: Two or more self limiting problems such as well controlled hypertension, dontrolled diabetes, cystitis, allergic rhinitis, or simple sprain.
Moderate: One or more chronic illness with mild exacerbation or progression, or two or more stable chronic illnesses. An undiagnosed new problem such as a lump in the breast counts as a moderate problem. Also the presence of an acute illness with systemic symptoms such as pylonephritis, pneumonia, colitis, or brief loss of consciousness is also a moderate problem.
High: One or more chronic illness with severe exacerbation, progression or side effects of treatment. Acute or chronic illnesses or injuries that pose a threat to life or bodily function, such as multiple trauma, acute MI, pulmonary emboli, severe respiratory distress, acute renal failure, seizures, TIA, CVA, or sensory loss.

The gem in the E/M billing system is that in order to bill for the appropriate level of service, the physician must document appropriately. Physicians cannot be billing for a higher presenting problem with 60 minutes of counseling time when the diagnoses is urosepsis with diabetes, and chest pain. The codes will simply not substantiate the higher billing! Make your physicians aware of the rules.

August 28, 2009 | shoffman | Comments 0

Few IPPS changes final rule could cause CDIs trouble

There are a few changes in the IPPS final rule that may prove problematic for clinical documentation improvement specialists, according to Robert S. Gold, MD, CEO of DCBA, Inc., Atlanta.

Hypoxic ischemic encephalopathy (HIE), for example, has its roots in the pediatric population. So it will be important to recognize that the code for an adult with HIE is 348.1— anoxic brain damage. “And we need to be specific about the causes of encephalopathy in the neonate,” says Gold, “they’re not all HIE.”

The 285.3 code for anemia due to anti neoplastic treatment is different from anemia due to neoplastic disease and different from aplastic anemia from chemotherapy. The CDI specialists has to know what cell lines are missing and determine the true cause of the anemia in order to frame the question to the physician properly.

Gold also suggested that CDIs require better specificity of location of blood clots currently under treatment with Coumadin in order to assign the right code for deep vein thrombosis. He also suggested that physicians need to document whether the condition is new during the patient’s current hospital stay or whether it had been under treatment from a previous hospitalization.

Finally, Gold urged healthcare professionals to “work to preserve” the terms acute renal failure and acute kidney injury and to totally downplay the new definition of acute kidney failure. “This is a misunderstanding currently under discussion. You don’t want to promote the use of a term that might not last long. You don’t want to have to re-teach,” he says.

August 24, 2009 | Melissa Varnavas | Comments 0

This is one case when you can't 'cut it out.'

Recently a client contacted me regarding a surgeon who asked the coding department to stop querying him about excisional debridements. His comment was that all his debridements are excisional. He’s a surgeon and he cuts. Bottom line. So please stop pestering him with the queries.

As most of us know, this clearly isn’t enough to code a record and has been the reason for a significant number of concurrent and retrospective queries across country in many, many hospitals. The simplest solution, of course, is for the physician to use the words excisional debridement but as we all know, that simple solution doesn’t always translate into simple reality.

What the client wanted to know was if they could make the assumption based upon his comment, that whenever he documented debridement, that he meant excisional and code to excisional. Again, I believe most of us would say that the documentation doesn’t indicate excisional and needs further clarification. So how do we get the documentation and not irritate the physician?

In an attempt to help clear the water surrounding the word “excisional,” many coding departments and documentation teams have made attempts to develop policies and procedures for clarifying this procedure. This became especially important with Recovery Audit Contractors (RACs) and other auditing agencies focusing on this specific procedure. Add to the mix the increasing number of elderly patients that are admitted with wounds that require care and then the number of non-excisional methods of treating these wounds. Clearly there is much to consider.

So what’s the best approach? Of course education is important. Physicians must understand the importance of their documentation and how a single word (or lack thereof) impacts the severity of illness, risk of mortality, and reimbursement. Communication of coding guidelines and definitions becomes an important function of a documentation improvement team.

Whether through queries, newsletters, posters or presentations, it is important for a documentation team to recognize the need for an ongoing method to provide support and resources to healthcare providers regarding documentation. We need to help providers learn the vocabulary that best represents the diagnosis and care they provide to the patient. Making assumptions or creating policies that allow for ambiguous interpretation of documentation will only create other problems.

So, clearly this particular surgeon needs to understand that if he performed an excisional debridement then he needs to document “excisional debridement.” Providing him with the information that defines an excisional versus non-excisional debridement is also important. Hopefully, once this information is shared, he will understand the need to include the appropriate words in his documentation. If not, that leaves the query process as an important part of the documentation process.

In answer to the question of whether it’s okay to eliminate queries for excisional debridement if the physician documents just debridement, only the provider knows the depth to which he or she cut and therefore it becomes the responsibility of that healthcare provider to document accurately and appropriately. I know this answer doesn’t necessarily make a CDI specialist’s day, but look at the bright side; it’s another opportunity to have a conversation with a physician and spread the word of complete and consistent documentation!

August 20, 2009 | Fran Jurcak | Comments 1

Query tip for principal diagnosis of fall admissions

by Joel Moorhead, MD, PhD

An article from the Journal of Trauma in 2006 documented that there are more than 770,000 yearly hospital admissions after falls—45% of all hospital admissions for trauma. A fall is surely the most common principal diagnosis that presents coding problems—even when there is clear physician documentation.

Attending physicians sometimes document ‘fall’ as a principal diagnosis but do not identify any specific cause(s) for that fall. However, coders cannot assign a code for a principal diagnosis without knowing what caused the fall, so keep these guidelines in mind:

Select a principal diagnosis from established conditions the physician has clearly documented.
Query the physician to obtain a principal diagnosis when documentation is not explicit.

Then, when querying a physician for more detail keep in mind a number of important factors. Falls are often multifactorial, due in equal measure to more than one established condition. When multiple conditions are eligible candidates for principal diagnosis, ICD-9 coding guidelines are clear that coders can sequence any of them as the principal diagnosis. However, when appropriate, ask the physician to clarify whether the documented causes equally contributed to the fall or whether one of the established causes is the principal diagnosis.

Nevertheless, the physician may not know the answer to the query. He or she may not know how that patient fell and received his or her injuries. So provide the physician an opportunity to say that he or she is unable to determine the answer to the query. This guideline is problematic when the coder cannot assign a code for the principal diagnosis directly from physician documentation. A coder’s health information management department may have a policy on whether or not to include an ‘unable to determine’ response option in queries for a principal diagnosis.

When a physician doesn’t reply to a query despite respectful encouragement, review the medical record carefully to determine whether the existing documentation sufficiently supports any established condition as the principal diagnosis.

Editor’s note: This post was adapted from our sister publication JustCoding.com. Joel Moorhead, MD, PhD is an adjunct assistant professor at the Rollins School of Public Health at Emory University in Atlanta. He is also a physician reviewer for FairCode Associates in Towson, MD. E-mail him at jmoorhe@sph.emory.edu.

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August 13, 2009 | Melissa Varnavas | Comments 0

CMS abandons IPPS payment reduction for now

Though many hospitals feared a 1.9% reduction in payment for 2010, they will actually see a 2.1% increase, according to the fiscal year (FY) 2010 IPPS final rule that CMS released July 31. CMS had originally proposed a documentation and coding adjustment to account for the effect of increases in aggregate payments due to changes in hospital coding practices that it says do not reflect increases in patients’ severity of illness.

The proposed adjustment would have resulted in historically low payments for hospitals and especially penalize hospitals that have yet to develop a clinical documentation improvement (CDI) program, says DeAnne Bloomquist, RHIT, CCS, president and chief consultant for Mid-Continent Coding, Inc. in Overland Park, KS. “I think that means that hospitals can breathe a sigh of relief.”

In the proposed IPPS rule, CMS intended to reduce future payment rates “based on the observed increase in spending due to documentation and coding that occurred in fiscal 2008,” according to CMS’ press release. However, because it does not have a full year of data that would show the extent of documentation and coding effects on 2009, CMS decided not to implement the adjustment until it has a full year of FY 2009 data.

In the next year, hospitals with CDI programs should continue their initiatives, while those who have not implemented one yet should work toward that goal, says Gloryanne Bryant, RHIA, CCS, CCDS, Regional Managing HIM Director at Kaiser Foundation Health Plan Inc & Hospitals.

August 04, 2009 | Melissa Varnavas | Comments 0

Documentation requirements for critical care services

In the July 23 issue of CDI Strategies, Robert S. Gold, MD, founder of DCBA, Inc., in Atlanta, offered a tip to help CDI specialists gain physician support for improved documentation in the medical record regarding critical care. In a subsequent e-mail, Gold added comments from his “guru” on physician professional bulling, Paul Dickson, MD.

Here is the amended information:

Critical care does not include ongoing monitoring of a patient who has stabilized, regardless of how many organs have failed in the past, but have now stabilized, how many lines and tubes were inserted, or how many devices were instituted. When the patient is stable, it is not critical care.

Too many physicians, however, do not realize that we can bill:

Critical care delivery by time increments for the first encounter

Additional critical care when the patient crashes again

A level three subsequent visit for noncritical care in addition to the critical care delivery on the same day

Any usual evaluation and management (E/M) service appropriate for services and documentation provided may be billed prior to a critical episode, but not vice versa. Consider the following case study.

A patient presents to the cardiac care unit after a coronary artery bypass graft. The patient is intubated with a left ventricular assist device still in place but is not active and receives low-dose dopamine for renal perfusion. The patient’s vital signs are stable with a little hypotension due to lack of vascular tone due to residual effects of anesthesia, however, it is easily controlled. The external pacer is in place, chest tubes are in place to underwater seal, and diluted urine is flowing through the Foley. A physician accepts the patient onto the intensive care unit (ICU) and performs an evaluation. The patient is not critically ill. However, the patient is on a respirator, and the physician manages that respirator. This may be ventilator management 94002-3 alone, and no E /M service may be billed with these codes.

In this case, the patient does not have acute respiratory failure. Writing the words “acute respiratory failure,” means a condition exists that involves the respiratory tree due to a disease process. If, indeed, the patient does have acute respiratory failure due to a disease process when he underwent the surgery, then it is appropriate to document that, if it still exists. If this is not the case, then the presence of the words “acute respiratory failure” will give the heart surgeon a black mark since the condition would be considered a complication of the surgery.

The following are a few examples of conditions that necessitate critical care: